244 S.A. MEDICAL JOURNAL 1 March 1958 , whom are available at the ame time. Where po ible tbe Ward accommodation, eparate from the general ward, medical officer should be well experienced and of senior should, if possible, be provided for staff. Accurate record of tatu . all attendances, injection, reports X-ray, etc., hould be uitable consulting and examination room mu t be pro­ maintained. Staff in general and nur es in particular should vided and ick parades hould start at an early hour in the not have access to their clinical records. However as with morning 0 that tho e who are fit to return to duty do not any patient, an explanation of the magno i is e ential. wa te time waiting r r the doctor. Facilitie for ick staff to Living-out taff who ab ent them elves becau e of illness report for iLlnesse that manifest themsel es after ick parade hould produce a medical certificate. mu t al 0 be available. The attitude, 'Get ick before 9 a.m. Personal Background. ]t i mo t important to get to know or wait till tomorrow', is a dangerou one that unfortunately your taff. Have they any dome tic worries? When did they exi t in many ho pital . last have leave? re they afraid of the Si ter in tbe ward in The head of the department to which a ick member of the which they are working? re they on day or night duty? staff belong (or a deputy) hould be informed that the staff Have they any pay querie that have Dot been settled? Are member ha reported ick, and of other facts that he officially they reafly suited to the particular work they are performing? need to know. The iter who a i ts the medical officer In hort. are they happy in the service? hould report back to the head of the department at the end CO CLU 10 of the sick parade indicating the name of tho e admitted and tho e put off duty. The diagno is hould not be di clo ed The object of a hospital administrator should be to keep to all and undry. down the taff ickness rate in his institution. In his work to this end comparative figures from other similar bospitals It is desirable that the ervice of con ultants on the staff are u eful. Measured in terms of sick pay alone the annual of the ho pital be a a'ilable; but all requests for consultations co t of taff ickne must be enormous. hould be made through the medical officer who conducts the ick parade. In turn the report should be sent to him in REFERE CES the first in tance. The taff doctor hould be regarded a the I. Mitchell. F. K. (1957): s. Arr. Med. J., 31, 671. 2. Hill. R. C. J. (1955): Ibid., 29. 344. family general practitioner who i always in the picture. 3. Editorial (1955): Ihid.• 29, 331.

lllSTORY OF AESTHESIA IN SOUTH AFRICA *

H. J. SCHMlDT, M.B., CH.B., M.MED. (A AES.)

When the Dutch East lndia Company sent out Johan van Riebeeck only item with analgesic properties mentioned in this list, as to the Cape of Good Hope it was with the intention of e tabli hing would be expected from the date of its publication. a half-way tation for their hips travelling bel\veen Europe and Further information can be derived from the records ofa med.ical the Ea t, so that the crew could be provided with fresh provision society \ hich f10uri hed in Cape Town from 1827 (or earlier) to for the long voyage which lay ahead of them. It took over 3 month 1847. On 2 ovember 1830 the members of this society laid down for the ailing ship to arrive at the Cape from Holland. The the following fees: ship' surgeons had a bu y time in deating with the many ai.lments £ s. d. £ s. d. For imroducing bougie. probang, catheter, extracting amongst the pa nger and the crew, becau e disea e, especially teeth, cupping, bleeding, and minor operations . . 0 3 0 to 0 15 0 curvy, \ as extremely prevalent because of the poor diet and For the operations of hare-lip, hydrocele, excision of unhygienic condition on board. tumours, tapping. amputation of toes and fingers .. 0 15 0 to 2 2 0 For reducing fracture and dislocations...... 1 10 0 to 4 0 0 In 1656, 4 year after van Riebeeck established the settlement For capital operations, viz., hernia, amputation, aneur- at the Cape, a ho pital had been built for the treatment and con­ ism. trep3.nniDg, lithotomy, extirpation of mamma, vale cence of patients on the incoming ships. In subsequent cataract, etc. 3 0 0 to 15 0 0 year the accommodation in this hospital wa found to be in­ Other interesting features of medical work at that time are adequate and bigger institutions were erect d by van Riebeeck's obtained from original papers presented at the meetings of this su ce ors. The Company hospitals admitted only their own ociety, the title of ome being: (I) Rupture of bladder; (2) opera­ employees, people who ailed on their hip or members of the tion for spina bifida, successful; (3) abscess of liver opened (1829); military gdrri on. (4) diffused femoral aneurism successfuJly treated by ligature of the In those day th Cape Colony had no medical men \ ith a external iliac artery (J 33); (5) a report of a chemical analysis of univer ity education. The barber surgeon and urgeons, who Cape opium; (6) gangrenou sloughing ulcer, cured by opium, had received their training by being apprenticed to a qualified gradually increased up to 125 minim daiJy of laudanum. 3 man, alone represented the medical profes ion. Their knowledge, This give us a glimpse of the events in those early days, but how however, wa limited. The barber surgeon knew only how to was the pain associated with certain conditions and operations treat wound, and the urgeon employed mainly bleeding and dealt with in the pre-anaesthetic era? purgatives for mo t of the ailment with which they had to deal. Dr. C. P. Thunberg, \ ho visited the Cape between 17 2 and I 75, report : 'Both in the ho pital and on board their hip, the Company PRE- AESTHETIC ERA had, for the great r part, ignorant and un killed surgeon; when a Some knowledge of this period is taken from the writings published kilful surgeon wa found he was a foreigner." by laymen. Peter Kolben in hi book Caput Bonae Spei Hodiemum Some 30 year later in a book published by the Batavian (p. 568) relates that the Hottentots, one of the original tribes Government in I 02, a list of the medicines and urgical equip­ inhabitulg the Cape had their own barber surgeons. They were ment i ued! gives ome idea of the operation that could be acqu~inted with the treatment of wounds and other injuries, with performed. Th li t covers amputations trepanning, herniotomy, cuppmg and with bleeding. When one of their patients had exci ion of fistula-in-ano and e traction of teeth. Opium is the abdominal pain, epiga tric discomfort or chest pain they did not admini ter internal medicines immediately but first resorted to • From the Department of Anaesth ia. niversity of Cape Town. Essay submitted in partial fulfilment of the ,equiremenlS for the degree of M.Med. cupping. A cow or ox horn was cut, leveJled and sucked to the naesthesia) of the University of Cape Town. area of pain until it caused the skin to become anaesthetic. The 1 Maart 1958 S.A. TYD KRIF VIR GE EESKUNDE 245

horn \ a then forcibly removed and the kin in ised with a few om e tent parallel imilar occurren described by Thoma cut about half an inch in length. ub equently the horn wa Key in hi book The Hi foryof urgical Anesthe ia. reapplied 0 er the incised area and kept in thi po ition until it filled with blood and fell off on it own accord. The procedure Ether took 2 or more hours depending on the depth and ize of the ut In the following year the pe Town ne\ papers teemed \ ith made. account from ove ea of the use of ulphuri ether by inhalation When confronted with a woman in difficult labour they admini ­ during operation to produce in n ibility to pain which, it wa tered tobacco or dagga mi ed with mil.k 10 ha ten delivery. This said superseded even the pretention of m meri m. t lhi time probably had its beneficial effect by acting as a narcotic.' public demonstrations of hypno i were being held in ape Town, This type of medication in ob tetries was not only used by the and from India report arrived of Or. James daile' \ ork or Hottentots. Kolben (p. 322) des ribes a case of ob tructed labour, operating on patient \ ho were in a hypnotic tate, a method in which a a last resort Virginian IObacco w hredded into which in later years \ a used \ ith ome uee in outh frica.8 water and the mi ture boiled, trained and cooled. fter the patient One of the ne\ papers" referred to Or. Henry BigeJow' addre , had taken the fluid-e tract by mouth, , he was deli ered of the whi h wa the first exten ive report to be made on ether ana _ child and of the violent pain'. One wonders what part the thesia, and wa read before the Bo ton oeiety of Medi al Improve­ ganglion-stimulating effect of nicotine played. ment in 0 ember 1846. (BigelO\ wa one of the urgeon at th When medical practitioner saw the need for producing insen i­ Massa husett General Ho pital.) The newspapers reported that bility they resorted to quite drastic method uch a bleeding their in England r. Li ton and other principal urgeon employed patient or putting them into hot baths until they fell into a tate the inhalation of ether during operation, that the veterinary {If yocope. In other the ame effect was brought about by forcible urgeon had equal succe s in their sphere of work, and that rectal injections of raw lin eed oil. To relieve any mu cular pa m Profes or Clemen or the ollege or ea, in e p riment on they admini rered alcohol by mouth or, if necessary, by mean of plan , concluded that they could be etherized as ea ily a man an enema.' and animal .'0.1! Opium was u ed with very much tbe same object in view as it is The fir t of the e reports appeared in pril I 47, about 6 month today, either as a hypnotic in the form of laudanum or as an after Dr. WilJiam Thomas Green orton had given the first enema in the form of opium crudum in ca es of dy entery. It was uc e ful public demonstration of the u e of an anaesthetic also applied topically for localized painful condition. (ether) during a surgical operation, at the a achu etl General Although these methods and preparations were employed on Hospital on 16 October 1846. 13 occasions to alleviate pain, there is no indication of their having published leller dated 24 pril 1847 from Dr. Montgomery at been used during operations. This has been pointed out by Mauritius describe the effect of ether on a patient who wa under­ Dr. P. W. Laidler in his historical articles.· going an above-elbow amputation." The date of these report Kolben (p. 636), who witnessed an above-elbow amputation in in Cape Town are in keeping with the long time taken for new Cape Town in 1708, describe it as follows: The patient, who had to travel from America and England. his hand and wrist shattered by a gun shot, wa brought to the operat.ion room from the general ward and seated in a chair. A. Raymond The barber-surgeon made his skin incision and with three move­ In South Africa, among t the enthu ia tic but ometimes also ments of the aw the operation was over. As the dressings were sceptical report, there appeared in 'De Verzamelaar id est: The applied the patient exclaimed his astonishment on being shown Gleaner' i ued on 20 April 1847 the following mall notice: the amputated arm. After having received a tonic and a heart 'Saturday la t, an experiment was made by the ;Ether Vapour by t.imulant he was returned to the ward but died a few days lat.er Mr. RAYMO D Surgeon Demist, having drawn from a Gentle­ 'from complications. man two teeth, and from an other one tooth, without causing A very good account of an operation performed in 1845 is any pain-we may therefore congratulate Mr. R. with the good given by Dr. Henry Bickersteth in the January number of the result of his experiment.' This, as far a can be determined, was Cape Town Medicnl Gazelle of 1847, the first medical journal to be the fir t reported occasion on which ether anaesthe ia wa published in South Africa. It was a case of an aneurysm, in which employed in South Africa. the left common carotid artery was ligatured. The day before the Mr. A. Raymond described him elf as a graduate from the -operation the patient was bled (10 oz.) by venesection. After the University of Paris; he had hi dental urgery in Cape Town at bleeding he felt easier, the throbbing pain in the head had decreased 27 Burg Street. In the following week he is reported to have used and he appeared calm and prepared for the operation. In his ether with great ucces, admini tering it from an inhaler which article Dr. Bickersteth writes: 'The patient having been laid on i , however, not described. In one instance in the middle of May the table with hi houlders raised, neck supported by a firm round 1847 he extracted a cariou tooth from the mouth of a mate who e pillow, and chin inclined towards the right side, the Operation ship was anchored in Table Bay at the time. After the extraction ·was commenced. . .. The man bore the operation, which la ted with the patient still in the uncon cious state he removed a larg~ about eighteen minutes, most nobly, scarcely uttering a word or wart from one of his finger with a ingle troke of the cutting moving at all during its performance. He expre sed no suffering forceps'. 'On the patient awakening Mr. R. expressed a hope when the artery was tied, but said he felt much relieved from the that he had not taken too great a liberty by so doing. "Far from -distressing pain in the head, ofwhich he had previously complained.' it, Sir' , he replied, "you have rendered me very great service In the account of the post-operative period it is to be noted that I hould long ince have had it taken off, could I have been ure on the 12th day, when the swelling increa ed in size and was a now, of it being wholly unattended with pain".''" ' tender to the touch, an opiate preparation was applied localJy and From the newspapers'·, '0 one is tempted to conclude that the ca morphine mixture given to relieve the pain. gentleman from whom Mr. Raymond was reported in De Verzame­ If these two descriptions represent the conditions of the pre­ laar to have extracted the two teeth was a medical practitioner. anaesthetic era in general, it would appear that the urgeons were His description of the experiment wa a follow: 'A general thrill inclined to operate on fully con ciou patients and, rather than pervades the body to it very extremities at first, and there occur rely on drugs for the relief of pain, depend on the rapidity with a series of, as it were, electric di charge in the brain-no better which they could complete the operation. simile is at hand. These feelings give way to a dreamy state, in which external objects partly enter and partly appear excluded: SURGICAL AESTHESIA SOUTH AFRICA: 1847-1900 to thi follow an utter forgetfulnes of everything. The oul appears to have cast off his earthly clog, and to be wandering it In South Africa 'laughing-gas parties' were quite a novelty in 1846. knows not where: in a word, there is a complete los of individual­ Members of the Cape TO\ n 10 titute borrowed a room in the ity, a feeling a if one were another person altogether. At this time Town House in which they demonstrated the effects of the gas. the operation was performed-the first tooth being extracted with­ The reactions of people, who inhaled the nitrou oxide from a out a trace of pain, though it appeared to di turb the lethargic bladder, varied considerably. In some the ga produced a state of state, so that a dull pain of a trifling nature accompanied the hilarious intoxication, others became stupefied, and in a few the removal of the econd. Shortly afterwards the writer awoke, gas apparently had no effect. As these exhibitions pro ided great discovering, to his complete amazement, two grim looking teeth amusement, it was suggested they should be performed in public on the table at his ideo 0 ill effect followed.' as a source of entertainment during the winter evenings! This to In the same article he write that he himself, in as ociation with 246 S.A. MEDICAL JOURNAL 1 March 1958

other, had uce fully experimented with ether, and concluded 'Smee' 'apparatu in which valves pre ented the mixing of inspired that thi was the Liquid which had been used in Bo ton by Morton. and expired gases. Thi provided greater comfort to the patient, (Dr. orton did not disclose the true nature of the substance at making r pi ration very much easier. Jt seems likely that thi the time, becau e he originally had intended to patent hi di­ greater comfort was due in part to the lower concentration of covery.) The practitioner then goes on to describe some of the ether vapour and the avoidance of re-breathing and con equent observation made in connection with ether anaesthesia. t first carbon-dioxide accumulation. The experimenters, on inhaling the patient almo t invariably held hi breath and coughed but the ether them elves, noticed no difference in the induction time afterward becoming accu tomed to the vapour breathed quite when either of the methods were employed. The experiments vigorously. Then followed a period of excitement, which passed with ether caused insensibility to pain in all except two or three off if the inhalation were continued to the point where there was cases. In these, failure wa attributed to extreme nervou nes of a 10 of refle es and mu cular tone, which indicated the stage the patient, and either to a poor quality of ether inhaled or an at which to start the operation. irregular working of the apparatus. A it wa deemed to be an To carry on in hi own word : 'In thi unconscious condition important acqui ition to urgery, it wa urged that the profes ion the patient will then remain for about three minutes: but it is at the of the colony gave the new discovery a full trial. It was uggested option of the operator to prolong the narcoti m to fifteen, twenty or they u e an apparatus imilar to their original one, which con­ even thirty minutes, without inconvenience to the generality of si ted of a large bullock' bladder containing a 2-inch-square piece patients. Thu the most tediou and evere operations of the 'of sponge oaked in 1 oz. of pure ether and filled with a tin mouth­ urgeon, whi h eldom exceed twenty minute, and are generally of piece, which would cover the lips and the angles of the mouth. a much horter duration, are capable of being performed during The bladder should then be emi-inflated with air and the nose of the tate of in ensibility. The 010 t curiou circumstance perhap is the patient firmly closed on each in pi ration. It was considered that the patient awake from hi lethargy alroo t at once; but for that the desired effect would be produced within 3 minutes and, ome hours after, he experiences an unusual buoyancy of pirits, in the extreme, within minutes. It was also suggested that the which only evaporates with the etherial odour itself. In a con ider­ inhalation of the ether might prove itself to be a valuable palliative able number of experiment the loss of ensation seem general, but and edative agent in the treatment of spasmodic asthma and in the effects of the vapour are very various.' bronchiti of old people. He further describes the new remedy a : 'Simple, obvious, free The next quarterly i ue of the Cape Town Medical Gazelle from all how of my tery xcept so far as the phisiological action reported that failures in producing anaesth ia with ether had of the ether i concerned-the di covery ha , in the cour e of a also occurred oversea. The editorial pre umed that it might few month, established it elf in the faith of the public a thorough­ have been due to the indiscriminate use of the agent, and propo ed ly a the di coveries of Jenne-r, Harvey, and the other ma ters of that the admini tration should be re tricted to patients who did medical science. Jt is true that different operators may meet with not suffer from head and chest diseases or who were not addicted different succes , according to the perfection of the apparatus to opium and brandy. It further relates that 2 amputation had employed and the usceptibility of the patient; but this i no been performed in Cape Town since the la t issue of the journal. more than what attends the introduction of every new process­ In the first operation, on a woman of 55 years with arterio c1ero is expertnes and certainty can only be acquired by an enlarged and in a poor state of health, the patient noticed that the amputa­ experience.' tion was in progress when she heard the saw passing through the So much for the write-up by the unidentified medical practi­ bone. In the other patient, although insensibility to pain had tioner, \ hich appeared in the Cape Town Mail of Saturday 26 June been produced the day before the operation, this degree-of success lS47. could not be obtained during the actual amputation because of a defect in the apparatus employed. Other reports seem to indicate Henry Ander 011 Ebden that the practice of 'trial inhalation' the day before operation was Other evidence that experiments with ether had been carried not infrequenl. out in Cape Town since April IS47 is found in the Cape Town Medical Gazelle, of which Dr. Henry Ander on Ebden (Fig. I) J. Esterllllyse wa the editor. In the editorial of the July number (written in the ot only did man benefit by the new discovery, but it was also editorial plural) the investigators describe the apparatus which used with advantage in operations on animals. In a communication they employed in the early trials. Later, however, they used a from Stellenbo ch dated IQ May IS47, it was reported that Mr. J. Esterhuyse removed a tumour weighing 2{- lb. from the lower eyelid of a horse whilst the animal was under the influence of sulphuric ether. The apparatus he de igned was simple, practical and effective. A sheet of wax cloth was rolled to form a cone. The wider end was fixed around the muzzle of the horse and the other end was attached to the ether bottle, which was placed in hot water. Within It minutes the animal feU and remained motionless for IS minutes, during which time the growth was exci ed and a hot iron applied to the woundY William Guyboll Atherstolle Whil t ether anaesthesia was becoming established at the Cape, a medical practitioner in Grahamstown, Dr. WiUiam Guybon Atherstone (Fig. 2) reported his sucees with ether in abolishing pain during an amputation. This report appeared in the Graham's Town Journal on 19 June IS47, and in an article by Dr. Atherstone in the same newspaper dated 26 June lS47. For ome time he had experimented \ ith ether in different types of apparatus with and without valves. He eventually decided to use a 2-quart bottle containing 2 oz. of ether topped with a cork through which 2 holes had been bored (Fig. 3). Through one aperture he pushed a gla tube t inch in diameter until the one end reached a po ition ! inch from the ether urface. In the other hole an elastic tube with an ivory mouthpiece wa fixed for the inhalation of the ether vapour. Both tubes were then blocked for some minutes to allow the air in the bottle to become saturated with ether vapour. After this the apparatus was ready for use. ·Dr. Atherstone emphasized that the success of producing anaes­ thesia depended on the rapidity of induction. He contended tliat Fig. I. Dr. Henry Ander=n Ebden. rapid e aporation of the ether should be aimed at by increasing Fig. 2. Dr. William Guybon Alherslone. the surface area of ether rather than applying heal. For this 1 Maart 1958 S.A. TYDSKRIF VIR GE EE KUNDE 247 rea on, and al 0 that the vessel might contain ufficient ether Ea tern Provin e he sent a detailed de ription of the pr edure to apour, he used a large bottle. He found that if the ether bottle the ne papers. were placed in hot water-a method which he had een recom­ mended in Engli h paper -the patient was unable to inhale the Chloroform vapour. It produced a burning ensation in the chest and eau ed To\ rd the middle of I 4 the news of a new liquid v hi h had the patient to cough.'· the ame effect a ether rea hed outh fri a and in ugu t of He further recommended that the elastic tube hould ha e a the ame year this lat t medi ine perchl ride f forn1yle, or large enough diameter to dimini h the r i tance to in piration, chloroform, was being advertised to ha e arri ed in rahamstown.l!O the r piration hould be low and deep and the breath hould be n 26 ay I 49 the Graham's Town Journal reported on an held at the height of in pi ration for a few seconds before the g operation \ hi h Dr. \. G. therstone had perform d a fortnight was e haled. previou lyon a young man, John wan, \ ho at the time had been The operation was performed on Mr. F. Carli le, the Deputy anaesthetized \ ith hloroform. fter the operation, which wa heriff of Albany, who had suffered from a contracture of the leg for the e i ion of a wen in the front of the neck the patient for 27 years. In the cour e of time an ulcer had formed. He would declared that he had not felt the light t pain and the only event have had the limb remo ed years ago had it not been for the pain of the operation he uld recall \ a that of a onfu ed unea y a ociated with uch an operation. fter he had inhaled ether dream. vapour and had satisfied him elf that it could deaden pain, he In Cape ToWD the first public announ ment of the u ful consented to the operation under the condition that he would u e of chlorofom1 locally appeared about a year later" after give the signal when the urgeon could begin. So on Wednesday Dr. Biccard had admini tered the anae thetic for the fourth time. 16 June 1847 everything was et for the amputation. fter the On thi occa ion he gave it to a woman for the remo al of a tumour in each brea t 10 prevent cancer. 'She inhaled for a few minutes Chloroform 10 about the quantity of a dram and a half. pon her being 0 ercome by its effect the operation wa commenced and finished without her feeling any pain.' The article ended by aying it hoped to serve the country inhabitants, \' ho were unable to acquaint themselves with the increa ing method for alleviating human uffering and were pining under diseases which could only be removed by urgical skill, and that they 'will find omething in this hort statement to cheer their pirit, and enable them to meet the dreaded hour of the surgeon's call with a compo ure to which they would have been tranger .'2' Thus the first great tumbling-block in the advancement of urgery had been overcome, but another big problem till had to be 01 ed. Thi problem was that of ep i , \' hich wa respon ible for an e tremely high mortality and morbidity rate amongst patient treated surgically. Carbolic At a time when the world wa acclaiming the uccess of ether anaesthesia the Hungarian Semmelwei publi hed hi treati on asepsi in 1847. In dealing with puerperal mortality he wa convinced that direct contact of undi infected hand and material was the cause of sep i in the uteru. By disinfecting the hand in Fig. 3. ther tone's ether apparatus. chloride of lime he reduced the puerperal mortality from 9·9 to 1.3 %. Although he had a few followers hi work was not recog­ patient had inhaled the ether vapour for a short while, he pinched nized by the majority. Twenty years later, Li ter presented his himself repeatedly to a certain the degree of insensibility. Even­ antiseptic technique in the treatment of compound fractures. tually he gave the word that the operation could commence. For many year he too had to fight for the acknowledgement of Dr. W. G. Atherstone, assisted by his father and two other medical hi theories again t the opposition of his professional brethren.!> practitioners, amputated the thigh through the lower third. As the One of hi first follower in South Africa wa Dr. J. P. Fitzgerald nerves and vessels were cut the patient gave an involuntary scream. of King WilIiam's ToWD. The Colonial Government had drawn When the leg was off the ether bottle was taken from the patient hi attention to Lister's ideas and method. In a letter dated and he started recovering. The whole procedure had taken about 6 March 1869 addre ed to the Colonial Secretary at Cape Town, 3 minutes. he writes on his experience of using carbolic acid in the treatment When he had come to his senses Mr. Carlisle said: ' ... it's the of extensive lacerated wound and mention that he had u ed it as greatest boon ever conferred on man, I have been totally uncon­ a dressing after amputations. He wa most impressed by the scious of everything-the ound of that horrid saw till grates upon udden ce ation of pain after the application of carbolic acid my ear as if heard in a dream from which you have just awoke me, on se eral contused and lacerated wound and by the freedom but as for pain I have not felt the slightest.''" (He recollected from local and con titutional disturbances resulting in the rapid later that he had a dream of attending an amputation on another recovery of his patients." This is the first reference to any form of person.) The patient did well after the operation, except for a local anae thesia in South frica by the application of drugs. period of delirium tremens attributed to the sudden cessation of To this day phenol has its place as a local anae thetic for topical opium applications, which he had been putting on the ulcer for application and as a powerful di infectant. However, mortality years. This episode was checked by the admini tration of a following urgery remained relatively high until Semmelwei ' laudanum enema. teachings of asep is were brought to light again by Schimmelbu h It is of interest to record Dr. Atherstone's observation during under the guidance of von Bergmann. Thus the present era of the operation and his view on the mechanism ofproducing muscular a eptic urgical technique wa born in I 5." relaxation. When he had cut the arteries and veins he noticed that the blood issuing from both was dark. He realized that thi was Chloral due to sub-oxygenation and voiced a warning against carrying In the mid-1870s Dr. J. F. Alien of Pietermaritzburg experi­ on the ether inhalation for a long time. He pointed out that, where mented with chloral a an anaesthetic for children. fter the previously several assistant had been nece aT)' to overcome the administration of 45-60 grains the tate of uncon iou n per­ muscular resistance in reducing di location and fracture, now i ted for 3-4 hour. He found that thi type of anaesthetic was not 2 ether could be employed to provide adequate mu cular relaxa­ attended \ ith ucces in adults. • tion,! but erroneously attributed the relaxation more to the partial a phyxia than to the ether itself. Chloroform and Ether To ensure that all the medical practitioners would benefit by When operations were performed, and in tho day they were the new discovery and becau e there was no medical journal in the few and far between, chloroform wa the ana thetic cho en in 24 S.A. MEDICAL JOUR AL 1 March 195 the majority ofcases.'· In ob tetrical practice, however, chloroform years ago. He contributed many articles toward the medi aJ was only employed in isolated in tances, and craniotomy was literature. preferred to Cae rean ection;" one presumes that the former wa performed without anae thesia. Ethyl Chloride Where general practitioners were separated from one another Whil t he wa in England he invented the Daniell ethyl-chloride by hundred of mile, they were obliged to operate single:handed. inhaler (Fig. 4) which was then considered the best of it kind. The doctor was both anaestheti t and urgeon. After mducmg It allowed for the gradual admini tration of ethyl chloride, wherea anaesthesia him elf, he handed 0 er the admini tration of the beforehand ampoules bad been cru hed and the liquid poured. on to a ma k allowing but poor control of vapour concentration. anae thetic for its maintenance to the local village con table or inhale~ the chemist, to the teacher or the patient's wife, to the denti t, or The came into use in Soutb Africa in 1904. Before thi even to hi own 'Cape boy' cart dri er, whil t he himself carried time ethyl chloride had eldom, if at all, been employed in thi out the operation and al 0 kept a watchful eye on the general country. In a letter which appeared in September 1904 in the condition of the patient a well as on that of hi lay helper; the watchword being, as expre ed by James Syme's aphori m, 'attend to the re piration , never mind the pulse'. Deaths under Anaesthesia The practitioners rarely admini tered ether alone; u ually it was in combination with chloroform or with chloroform and alcohol-the A.C.E. mixture, which contained the agents in various proportions to individual liking. The main reasons given for the uncommon use of ether were it pungent property and the lack of teaching in anaesthesia. Chloroform was more ea ily administered and the induction was more plea ant to tbe patient. ]n 1907 only 8 out of 22 medical examining bodies in Great Britain required students to how evidence of instruction in anaesthesia, but in 1911 the General Medical Council of Great'Britain stated that all medical examining bodies required their candidate to how proof of knowledge and training in anaesthesia}' The majority of tudents con idered it a necessary evil to study anaes­ thesia to comply with the regulation, and after qualification the young doctor showed very little interest in the admini tration of anaesthetic, which was chiefly by the 'rag and bottle' method. However, the increase in the deaths with chloroform admini ­ Fig. 4. The DanieU ethyl-chloride inhaler. tration , often occurring during the induction period, became a Fig. 5. The Clover ether inhaler. matter of great concern amongst the medical profes ion. In South Africa the death of a per~on whilst under the influence of a general SOlllh African Medical Record, Dr. C. J. Hill Aitken from East anaesthetic wa subject to investigation by the Resident Magi trate London wrote that ethyl chloride was as safe as gas and much or Field Comet becau e of the interpretation of the Tnque tAct handier, becau e the inhaler and the glass cylinder could be carried of I 75, and later of 1919. Before thi , the holding of an enquiry in a mall handbag. 'Without doubt it will be a boon to the in cases of a sudden aeath had become necessary by cu tom in the Profession and to the public.' At first ethyl chloride was used Cape Colony;'" it became a written law with the promulgation continuously throughout operation, but this technique was s~on of the Act. To-day the same regulations are valid by virtue of . abandoned {lnd its primary function became that of an mducmg section 6 of the Medical Dental and.Pharmacy Act, 192 . agent and ether was administered for maintenance. It was oon recognized by many that chloroform wa not uitable for patients sitting in the dental chair and that the pro­ itrolls Oxide portion of deaths during anae thesia was higher at Johannesburg The gas referred to in the above letter is nitrous oxide. As than at sea level. By far the majority of fatalities at Johannesburg the continuous-flow method of administration, which required took place when the patient were under the influence of chloro­ large quantilie of the gas, was the only one known at the time, form. 311 In the last decade of the nineteenth century and in the practitioners, for economic reasons, u ed it sparingly. They mainly beginning of the twentieth medical men in South Africa voiced gave it as an inducing agent, for short operations and .in dentistry. the opinion that ether wa safer than the generally used chloroform, The preparation of the gas involved high cost and It had to be and 0 ether became more frequently employed. One of the shipped from England to South Africa. For refilling, the cylinders advocates of a change in thi direction was Dr. George Warwick were sent back, where they were tested by the English Board of Bampfylde Daniell, the first specialist anaesthetist in South Trade and sometimes discarded without compensation. When the Africa. compressed gases were returned they could only be transported at special rate and on special ships as deck cargo. It took at least THE MODER DEVELOPME T OF A ESTHESIA I so TH AFRICA 3 months before the cylinders reached their owners again. During the 1914-18 war the shipment of the cylinders was prohibited; George Warwick Bampfylde DoniI'll after the war until the early 19305 the administration of the ga Dr. Daniell qualified in 1 88 M.R.C.S. (Eng.) L.R.C.P. (lond.). remained uncommon here except for bad-risk and special (e.g. The following year he came to the Cape and set up as a general diathermy) cases. 31 It was only in 192 that the firm Alien Liver­ practitioner in Caledon, where he remained uotil 1897. After the sidge Indu trial Gas (SA. 1927) (pty.) Ltd., Johannesburg, later Boer War, in which he acted as a Civil Surgeon, he left for England known as African Oxygen and Acetylene (Pty.) Ltd., manufactured to devote his time to anae thesia and wa appointed as an anaes­ nitrous oxide in Johannesburg on a commercial scale. The plant thetist to various hospitals in Great Britain and as a lecturer in they in tailed was capable of producing several times the then anae. the ia to medical tudent. In January 1906 he returned to known requirements of the Union, Rhodesias and adjacent South Africa and began to practice in Cape Town, confining him­ territories.·' The development of the re-breathing and carbon­ elf entirely to hi peciality. year later he moved to Johannes- dioxide absorption techniques and the local preparation of nitrous burg, where he had been appointed as a specialist anae theti t o ide broueht down the cost of this anaesthetic to a reasonable to the Johannesburg General Hospital. After his resignation in level, and the urgeons, at the requ t of their patient, gradually J90 he wa succeeded by Dr. Frank Bumand udd. In 1921 increased their demand for nitrous oxide and oxygen anaesthesia. Dr. Daniell and Dr. Mudd accepted the le tureship in anaesthesia at the Cape Town and Johannesburg medical schools respectively. Oxygen Ten vears after his retirement Dr. Daniell died in Port Elizabeth . Shortly after Dr. Daniell started his anae thetie practice in on J6 January J937. In hi time he wa regarded as the highest South Africa he gave demonstration of nitrous oxide and oxygen South African authority in anae thesia. He designed and modified anaesthesia throughout an operation,3. but its use remained various appliances, some of which were in use as recently as 10 confined to i olated case for a considerable time. When he 1 Maart 1958 S.A. TYDSKRIF VIR GE EESKU DE 249

mo ed to Johannesburg he found that neither nitrous oxide nor of perforated celluloid in which the holes had been partially oxygen as available at the Gen raJ Ho pitaJ.Sl It was not the QC luded with a ponge or a piece f flannel. Dr. Daniell modified practice to admini ter oxygen in as ociation with anaesthetic thi apparatus by ping the air and 0 gen first through a coil agents. The original idea of adding 0 ygen to an anaestheti wa immer ed in hot \ ter and ub qu ntl through the ether. From to dimini h the respiration, but Dr. Daniell emphasized the the ether container the apour reached the patient via the warmed safety and comfort it contributed in anaesthesia. However, in coil as already described (Figs. 7 and ). When the patient' own 190 oxygen was not easily obtainable and the tran port of the r piratory mo ements had been aboli hed the pumping m hani m cumber ome cylinders with oxygen and nitrou oxide further maintained adequate ventilation. Thu ,thi method of controlling limited their use. especially in country di tricts. respiration has been nown for 0 er 40 year.· 1t probably, To overcome thi disadvantage a portable apparatus called however, operated largely through diffu ion respiration. 'Oxone' generator was adverti ed and probably used to obtain practitioners realized the afety of ether as an anne thetic oxygen. 'Oxone', a compact preparation of hydrogen peroxide, agent it use increased and by 19_1 hipway's warmed-ether produced oxygen when brought into contact with water and it was apparatu had become 0 popular that it wa u ed e tcosive1y b alleged to be generated at the exact peed required for the inhalation private practitioner and in ho pital throughout outh frica.'· in a man' lung. It enjoyed that po ition for a quarter of a century. In 1908 the ew Transvaal Chemical Co. Ltd. manufactured Ether was first produced in SOIll}, Africa on a commercial scale oxygen on a commercial basis and in 1915 Le er Bro . (SA.) in January 191 by the firm The atal Cane By-Products, Ltd., (Pty.) Ltd. took a controlling interest in this Company. The good­ which had been establi hed 3 ears previou I. nae thetic ether will, plant and stock of Lever Bms.' oxygen business at Denver was imported from oversea before thi , and till i to ome e tenl." and at CongelIa, Durban, were disposed of to the Alien Liversidge Local anaesthesia wa not frequently employed by practitioner Company 12 years later.3. in South Africa. It regular use wa mainly confined to the ophthal­ Although oxygen \ a being manufactured in thi country, mologi t and the dentist,. t first only those trained on the its price remained high for many year, which of course did not Continent practi~ regional anaesthesia. encourage its use. During the First World War a shortage ofoxygen cylinders caused an irregular supply, and even for some years later Lumbar Anaesthesia. At the South frican Medical ongress these cylinders continued to be a novelty."· held in Pretoria in 1907. Dr. E. F. . thamer read a paper on Lumbar Anaesthesia and its practical application in surgery, in Ethylene was not used in South Africa to any extent, the only which he gave a description of the method and some of hi record I could trace in this respect was in connection with experi­ experiences with thi type ofanaesthesia 42. However, the difficulty ments made by Dr. T. Greenwood Hall in 1921. He had saturated in ma tering the technique of spinal, caudal, epidural and nerve­ ether with ethylene and carbon dioxide and used this agent as an block infiltrations and the time nece sary to perform them hindered anaesthetic in surgical and dental operations. At about the same their extensive u e. time a description of this anaesthetic, called 'Ethanesal', appeared in a resume of a paper by Dr . Wallis and Hewer in the BritiSh Pre-operative Care. Another important de elopment which edical Journal.37 took place in the fir t 2 decade of thi century was the more The commonest method of admini tering anaesthetic was the adequate preparation of the patient for an anaesthetic. Whereas open one by means of the wire-framed mask covered with lint or anaesthetists hardly ever examined their patient y tematically wide-mesked gauze, but the practitioners did employ others as beforehand and, if they did, then it wa only where there wa a well, uch as the Clover inhaler with its modification (Fig. 5), u'picion of heart or pulmonary disea e, it now started to become the Shipway apparatus, or rectal and local anaesthesia. a routine. It wa urged that blood,pres ure readings hould be included to determine the state of the cardio-va cular system Endotracheal Tther-Oxygen. For operations around the head pre-operatively, and that urinary examinations would reveal and neck and where the practitioner had to work single-handed, important information. rectal anaesthesia was advised. 11 was given either by introducing warmed ether vapour or a \ armed mixture of ether and olive oil Premedication. Practitioners began to realize the benefit of the into the rectum. In 1915 Shipway' endotracheal ether-oxygen administration of drugs before the operation, not only a an apparatus came into u e. It was recommended for head, chest and adjuvant to the anaesthetic and a counter-balance to its ide, upper abdominal operations and for applying artificial respiration. 38 effects, but also to allay the fear in the patient' mind and to After the patient had been anaesthetized a catheter of uch a ize en ure a good night's rest. Atropine had been injected pre­ a to allow the expiratory gases to pas easily between the catheter operatively on ome occasions, chiefly to counteract the inhibitory and the laryngeal wall was inrroduced either down the larynx effect of the vagu on the heart; its u e became more frequent to or through the laryngotomy or tracheotomy opening which had minimize salivary excretion with the increa e in ether anae thesia. been made beforehand. By means of a hand bellows-in later By some hyoscine was favoured becau e of its additional depre ant years by a foot bello\ s or by an electric motor working a rotary • The first apparatus for maintaining prolonged periods of artificial re piration blower-air alone or with oxygen could be pumped through the was demonstrated by Dr. W. Steuart in Johannesburg in 191. It was made ether container. The ether vapour was then led through a coil for the treatment of children suffering from respiratory failure in an epidemic immersed in a hot-water receptacle (Fig. 6), and from there the of anterior poliomyelitis. As. however, the apparatus was only completed aft.er the last pat:em had died he called for suggestions which would render it more warmed ether vapour reached the patient either through the efficient should it come i.nla operation. \"hereupon it was proposed that a dog endotracheal catheter or via a mask made of porous material or should be fully curarized to act as a test. Jt

Figs. 6, 7 and 8. Daniell's modification of Shipway's endotracheal eLher-oxygen apparatus. 250 S.A. MEDICAL JOURNAL 1 March 1958

effect. The addition of morphine to the premedication al 0 put THE STATUS OF ANAESTHESIA IN SOUTH AFRICA the patient in a calm state of mind, and reduced the amount of anaesthetic required during the operation. At first an objection By force of circumstances a general practitioner of the early days to this u e of morphine was that it affected the size of the pupil often had to call in the help of laymen to give anaesthetics. Only and thus interfered with an important ign of the depth of anaes­ 30 years ago the following tatement was made: 'Any practitioner thesia, but practitioners soon learnt to put more reliance on the can legally employ anyone whomsoever as an anaesthetist, he type, regularity and amplitude of the respirations and on pulse shouldering the whole responsibility'. 55 Such action, however, and blood-pres ure readings. Authorities advised not to give too was condemned except in 'special instances: but it was doubted large a dose of morphine, becau e this delayed the return of if any Medical Council (until 1927 every Province of the Union reflexes and ofconsciou n , and to be wary in giving it to patient had its own Medical Council) would regard it a a ground for with increa ed intracranial pre ure and ad anced re piratory disciplinary action. disease. At times patient received cWorbu 01 (Chloretone), Tn 1917 the Federal Council of the Medical Association of South pota ium bromide or barbitonum (Veronal) as ubstitutes for Africa passed rules for professional conduct which inter alia set morphine in the premedication. out that it wa detrimental to the honour and interests of the On some occa ions the morphine-scopolamine combination in medical profession to employ an unregistered person as a paid repeated do es con tituted the ole anaesthetic, which if neces ary anaesthetist at an operation.55 Nine years later the South African could be supplemented by ether inhalations. Thi combination Medical and Dental Council put the matter quite clearly by also found it use in obstetrics to produce 'twilight sleep', but the resolving 'that tbe administration ofanaesthetics was an act pertain­ danger of respiratory depression in the newborn wa repeatedly ing to the calling of a medical practitioner.'57 Dental practiti(;mers, empha ized. however, had been administering anaesthetics since the early days and according to a notice sent to them in April 1938 were permitted In the conduction of anaesthesia Dr. Daniell stressed the to give nitrous-oxide anaesthesia. This apparent restriction was importance of a clear airway, adequate oxygenation, and free done away \vith in 1944 by a resolution passed by the South African chest expansion. Apparently the anaesthetists of that time had Medical and Dental Council, which read: 'The Council further difficulty in dealing with their female patients, who were reluctant resolved that in the practice of dentistry, the administration of to loosen their cor ets sufficiently. An American gynaecologist anaesthetics by dentists should be unlimiteq'58 and some provisos estimated that they produced an all-round pressure of 30 lb. were added. Intravenous Anaesthetics. A new era in the administration of When the registration of specialties was introduced in 1938 to anaesthetics commenced in this country with the introduction of 43 protect the public and medical practitioners from th~ pseudo­ hexobarbitonum solubile (Evipan sodium) in 1933. 11 provided specialists, anaesthesia was listed among the speclaltles of a rapid and pleasant induction, thu avoiding the feeling of suf­ medicine. 59 The regulations governing specialization since that focation produced by the mask. It is true that basal narcotics time have been revised from time to time. After the Second World such as the rectal admini tration of bromethol (Avertin) since War a medical practitioner had to be in the possession of a higher 1930" and the intravenou injections of butyl-,8-bromallyl barbitone qualification in Anaesthesia in addition to other requirements, sodium (pernocton sodium) and of pentobarbitone sodium before he could register as a specialist anaesthetist. The Wit­ ( embutal) had been employed, but it was Evipan odium which watersrand Medical School, Johannesburg, was the first to provide popularized the use of intravenous anaesthesia. The drug now facilities for such a higher degree to be taken in South Africa, most commonly used for this purpose is thiopentone sodium instituting the Diploma in Anaesthesia"· in 1947. Tn later years (Pentothal sodium), which Dr. C. W. H. van der Post, of Durban, the University of Pretoria and the University of Cape Town also administered for the first time in South Africa in 1936. '5,45 made it possible for medical practitioners to obtain a higher Although a 10% solution of the drug was injected originally, qualification in Anaesthesia. '.. experience taught that a lower concentration provided a more During the last war, on I August 1943, the South Afncan Society accurate do age, which contributed to greater safety, and also of Anaesthetists was founded in Johannesburg. Tllis organization made perivascular reactions less likely to occur if some of the is a Group of the Medical Association of South Africa and has as solution were inadvertently deposited in the tissues. its main aims (a) the promotion of the science of anaesthesia; ew Inhalation Anaesthetics. Two years previously a new (b) the correlation of the interes.ts. of all practisin.g an<;testheti.sts inhalational anaesthetic, cyclopropane, had been brought out to in South Africa and the determmmg of the relatIonships which South Africa by Dr. Royden M. Muir.47 During his visit to the should exist between anaesthetists, and between anaesthetists and United States of America .in 1933 Dr. Waters of Madison coached hospitals (public and private), Government authorities, the general him in its use. Encouraged by what he had seen in America, and public and the medical profession in general; and (c) to represent after some experience, he took 2 cylinders filled with cyclopropane and further the interests of anaesthetists.61 back to England and gav the first administration with it in 5 At the instigation of this society a separate Section ofAnaesthesia London.' On his return to South Africa he started giving it in was formed for the first time at the 34th (1st post-war) South Cape Town. 11 u e, however, remained limited mainly owing to African Medical Congress, which was held in Durban in October the high cost of the gas. 1946. At the end of the opening plenary session on the 'Conquest After the Second World War many developments took place of Pain' the Congress passed a unanimous resolution stressing the in the field of anae thesia. In 1946 another new inhalational desirability of founding Chairs in Anaesthesia at the South African anae thetic, trichloroethylene (Trilene), made its appearance in 5 49 medical schools. ' The University authorities did not consider the South Africa. 11 was to replace the chloroform in using the time ripe for this action. Tn 1947 none of the medical schools had # Boyle's apparatus. Thi machine gained in popularity and gradually well organized departments of anaesthesia, but since that time the replaced other appliances to a large extent. lis use, or that of an position has greatly improved by the appointment of full-time apparatu re embling it in con truction, became imperative with teaching staffs. the advent of curarimimetic drugs a a means of assisting or con­ evertheless, the recommendations made by the Commission trolling the respiration by intermittent positive pressure. of Inquiry into Anaesthetic Deaths, appointed by the Govern­ Relaxant Drugs. Whereas good relaxation could previously ment in January, 1936,"3 have only been partly observed, for it is only be achieved with local or deep general anaesthesia, intra- possible that an intern at certain institutions may go out into enous injection of d-tubocurarine chloride now gave the same general practice without having given a single anaesthetic during effect with light general anaesthesia. South African anaesthetists his internship year. This has been criticized for the reason that the gained some experience of d-tubocurarine chloride at the various theoretical as well as the practical teaching of anaesthesia is of theatres of war, but its more general u e in this country, as Into­ great importance in the training of students and interns, if skilled co trin, dates from 1946.$0 medical practitioners are to be provided throughout South Africa After this, various other relaxant drugs were. tried out-galla­ for the safe administration of anaesthetics. mine triethiodide (Flaxedil)51 and decamethonium iodide Tn the past a comparison has been drawn between intravenous (Euli in)" in 1949, uccinyl chloride (Ly thenon, Scoline)53 in anaesthesia and the Libyan Desert, which Rommel is reputed to 1952, and laudexium methosulphate (Laudolissen)54 in 1953. have described as a tactician's paradise and a fool's graveyard. Furthermore, in recent years hypotension and hypothermia, have To-day this analogy could well be applied to every sphere of anaes­ been developed a adjuvants to general anaesthesia, which in thesia. If the present-day anaesthetist is to fulfill the demands selected instances have been a valuable aid in various operations. required of him for the benefit of his patients and to facilitate the 1 Maart 1958 S.A. TYDSKRIF VIR GENEE KUNDE 251 work of the urgeon, he must po es a good knowledge both of 30. Daniell. G. \ . "B. (1913): Med. J. . fr.. 9. . 31. Muir, R. M. (1934): urr. R. ne th., 13, 53. hi own pecialty and of the basic and clinical scien es of medicine. 32. lIen-Liversid e Industrial G es, ewtown, Johannesburg (19- ): J. ed. .. fr.. 2. 504. REFERE CES 33. Daniell, G. \ . B. (1920):. r. 1ed. Rec., 18, 79. 34. Idem (1920): Ibid.. 18. 330. I. Botha, C. G. (1949): MMicine in the early days of the Cape. Souvenit Bro- 35. Lever Bro .(. .) (Ply.) Ltd. Personal communi alion. chure. 37lh S. Afr. Med. Congr., Med. .. Mr., p. 36. Cape Town: 36. 1uir. R. 1. (1944): . fr. 1ed. J .• I, 345. Peninsula Press Ltd. 37. Hall, T. G. (1921): 1ed. J. . fr.. 16, 191. 2. R~g~ling van d~n G~n~eskundig~n Diensr, bij de Troupes du &raafscJre 3 . Rep. Brit. 1ed. soc., G.H. eslern) Bran h, linical meeting lay Republiek. aan de Coop de Goede Hoop. I 02, upp. A, B, C. D. (1915): . Afr. Med. Rec., 13, 164. 3. Beck. J. H. M. (1894): History ofmedicine and medical practice at the Cape. 39. Rep., Brit. ed. ssoc., Witwatersrand Branch, clinical meeling (191 ): Presidential ddresses. C.G.H. (Western Prov.) Branch of Brit. Med. 1ed. J. . fr.. 13. 147 and 150. pp. 71 and 79. Caoe Town: Townshend. Taylor and Snashall. 1908. 40. Dr. G. \ . Bampfylde Daniell's imoroved apparatu for the administration 4. Menuel, O. F. (1787): Bnch"ibung des Vorgebirges du Guten Hofnung, of warmed ether vapours (1921): Ibid.. 16. 162. pt. 2, p. 468. Glogau: C. F. Gilnther. 41. alal Cane By-products Ltd. Personal communication. 5. Atherstone, W. G. (1897): S. Afr. Med. J., 4. 245. 42. thamer, E. F. A. (190 ): Transv. Med. J.. 3, 2 9. 6. Laidler. P. W. (193 ): S. Afr. Med. J., 12.454. 43. The Trade Exhibition: Bayer Produ ts Lld., London (1933): .. Afr. 1ed. 7. Sam Sly's Mrican Journal. 16 April, I 46. J.. 7. 660. 8. Long, E. C. (1899): S. Mr. Med. J.. 7. 32. 44. Moore Dyke. R. npubli hed data. 9. South Mrican Commercial Advertiser, 17 April, 1847. 45. Obituary. . H. an der Post (194): ewsleller. . Afr. . Anaesth., 10. Cape Town Mail, 26 June. 1847. 2.51. 11. South African Commercial Advertiser. 7 April, 1847. 46. an der Po t. C. \ . H. (1936): . fr. Med. J., 10. 599. 12. Cape Town Mail. 27 November. I 47. Quoting Mechanics' Magazine. 47. ObitDary, Royden Mcloto h Muir (19 ): Ibid., 22,77 . 13. Keys, T. E. (1945): The History ofSurgical Anaesthesia, p. 27. ew York: 4 Muir, R. M. (1934): Ibid.. 8, 175. Schuman's. 49. I.C.1. S. Afr. (Pharmaceuticals) Lld. npubli hed data. 14. De Zuid-Afrikaan. 27 May 1847. 50. "Barlow. M. B. and GinsberJZ. H. (1946): S. fr. Med. J., 20,44 . 15. Ibid., 20 May 1847. 51. Heoderson. G. G. (1949): Ibid., 23,91 . 16. Ibid.,3 May 1847. 52. Grant-\ hvte. H.. Cave, . J. and illiers, . A. (1949): Ibid., 23, 1030. 17. Ibid., 17 May 1847. H Roberts. F. \ . (1952): Ibid., 26. 636. 18. Ibid., 1 July 1847. Quoting Frontier Times. 54. Fuller. T. A. and Harrison. G. G. (1953): Ibid., 27. 1060. 19. Graham's Town Journal, 26 June 1847. 55. Editor (1927): Medica-ethical. J. Med. PC. S. Afr.. I, 69. 20. Ibid.. 19 August 1848. 56. Federal Council Minutes. Dec. 1927 (192 ): Ibid., 2. 17. 21. African Journal. 20 June 1850. 57. S. Afr. Med. Dent. Coun. rep. meeting ept. 19 6 (1936): S. Mr. Med. J., 22. De Zuid-Afrikaan, 3 June 1850. 10, 746 23. Besselaar. H. J. (1941): S. Mr. Med. J.. 15, 106. 5 . Rep. on A tivities of S. Mr. Med. Dent. Coun. 1955 (1956): J. Denl. A.soc. 24. Laldl~r. P. W. (1939): Ibid.. 13, 225. Citing Rep. on King William's Town HospItal for 1868: Cape ofGood Hope, Votes and Proceedings of Parliament, 59. ~: "i;:;: ~\·e~'6i:>enl. Council's Regulations for Specialists (193): . Afr. app. I, vol. I, 1869. 25. atal Witness, 22 February 1876. Cited by Hattersley, A. F. (1955): A 60. t1~v". Jo;' i~~a~~~rand Calendar (1947): p. 62. Johann burg: Horters Ltd. Hospital Century. p. 55. Cape Town-Amsterdam: A. A. Balkema. 61. Grant-Whvte. H. (1947): The d..elooment of anae"hesia in South Africa. 26. Mursell, H. T. (1904): S. Afr. Med. Rec., 2, 164. Address, 22nd nnual Congress of Aoaesthetists (lot. Anaesth. Res._Soc. 27. Murray, C. F. 1<. (1912): Ibid.. 10,9. and 1nl. Coil. Anaesth.,) ew York. Sep. 1947. 28. Muir, R. M. (1939): S. Afr. Med. J., 13,715. Citing Lunney, E. W. (1939): 62. Editorial (1949): S. Afr. Med. J., 23, 509. Curr. Res. Aneslh.. 18, 79. 63. Grenslem. A. J. and RobertSOn. L. S. (1936): Rep. Committu on Dtaths 29. Botha, C. G. (1916): S. Afr. Med. Rec., 14,55. under Anaesthesia, Ibid., 10, 731.

SODIUM· AND POTASSIUM BAL CE*

(1) IN RELATIO TO PERIODIC PARALYSIS AND (2) A CASE OF PYELOl'.'EPHRlTI WITH M LIG TA T HYPERTENSIO T

L. EALfS, M.D., M.R.C.P., G. C. LlNDER, M.D., F.R.c.P. AND I. SAKINOFSKY, M.B., CH.B.

From the Deparlmenls of Medicine, Neurology and Psychialry and Chemical Pathology, Universily OJ Cape Town' and Croole Scllltllr Hospital

Reversible temporary muscular paralysis including periodic 4. Serum-potassium level unknown (? hypokalaemia). paralysis has frequently been reported in association with dis­ (a) Pa Ping or Kiating paralysis (? barium poi oning). turbances of potassium metaboli m. It is clear that paralysis may occur with a low, a normal or a raised serum-potassium con­ We wish to report (I) a tudy of a case of sporadic periodic centration and in any individual attack the following possibilities paralysis, and (2) a case of pyelonephritis and superimpo ed arise: malignant hypertension, with hypokalaemia, but without para­ lysis, in which there wa renal odium wastage and an increased 1. Hypokalaemia aldosterone excretion in the urine. (a) Diminished intake + excessive gastro-intestinal loss of potassium. CASE OF PERJODlC P RALYSIS (b) Potassium-losing renal diseases. (c) Primary aldosteronism. Generally speaking information on balances in periodic paraly is (d) Classical familial periodic paralysis. is meagre, and scant attention had been paid to the state of odium (e) Sporadic periodic paralysis. metabolism in this disorder, until Conn suggested that there was an intracellular equestration of sodium prior to the attack and a (I) Periodic paralysis with associated thyrotoxicosis. naturesis succeeding the attack and that the disea e should be (g) Miscellaneous: Diabetic acidosis during treatment, treated with a low-salt regime after preliminary de-salting. alkalosis, P.A.S. intoxication etc. Thesubject of the present tudy wa C., a 17-year-old White-male 2. ormokalaemia from Kny na di trict, who had had periodic attacks of paraly i (a) Salt Lake City type of familial periodic paralysis. 2-3 times a week since the age of 6 years. Tbere wa no family history of imilar attacks, but hi father i said to have suffered 3. Hyperkalaemia from epiJep y. The attacks varied in duration from a few minute to (a) Scandinavian type offamilial periodic paralysis (adynamia several houn and they were mo t frequently nocturnal in onset; episodica hereditaria). exertion on the preceding day appeared to be a precipitating factor in some in tances. Their character varied from mild aching in (b) Chronic renal disease. muscles with light 10 of motor power to complete paraly i • Abstract of paper read at a meeting of Research Forum, University of from the neck down, although cranial nerves and diaphragm were Cape Town, held at Groote Schuur Hospilal, Cape Town, on 5 February 1958. never involved. CoDSCiou ness, the special enses and ensation